Finding into death of Kathryn O'Rourke
Deceased
Kathryn O'Rourke
Demographics
48y, female
Date of death
2018-05-16
Finding date
2021-06-23
Cause of death
Hypoxic/Ischaemic Encephalopathy; Aspiration of Food with Respiratory Arrest with Contributing Factors - Intellectual Disability
AI-generated summary
Kathryn O'Rourke, aged 48, a resident with severe intellectual disability and dysphagia in a disability residential care facility, aspirated a piece of toast during breakfast on 10 May 2018 and died from hypoxic-ischaemic encephalopathy on 16 May 2018. She had documented swallowing difficulties requiring modified food consistency and supervision during meals. On the morning of the incident, a single staff member was supervising multiple residents during mealtime with divided attention. A new seating arrangement designed to reduce choking risk had been trialled the previous day but not communicated to staff on duty, so was not implemented. Clinical lessons include: strict adherence to mealtime supervision protocols for residents with dysphagia; ensuring all staff are aware of and implement new safety measures immediately; maintaining one-to-one support during meals for high-risk residents; and regular training on aspiration risks in intellectually disabled populations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- aspiration of food during mealtime
- dysphagia with overstuffing behaviour
- divided attention of supervising staff member
- failure to implement new seating arrangement trial
- communication failure regarding safety protocol changes
- unstable mental health with escalating behavioural issues in days prior to incident
- intellectual disability
Coroner's recommendations
- Staff providing support to residents with dysphagia should receive training on active supervision and mealtime safety management
- Residents requiring one-on-one support at mealtime should not be left unattended or under supervision of staff assisting more than one resident
- Safety protocols and seating arrangements should be communicated to all relevant staff immediately upon implementation
- Regular training should be provided on safe mealtime supports, including reducing choking risk, ensuring appropriate food texture, small mouthfuls, upright positioning, and continuous monitoring
- Health and Wellbeing records should be reviewed regularly for all residents in care facilities
- Mealtime management plans should be regularly reviewed and medications regularly reviewed
Full text
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